Holland, Charles

®dCM1-1^•. AA / DREDGE & FILL 1 > p P / r No. 75029 A B ' C D
GENERAL PERMIT Previous permit# -'
jeff eyv ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ry
As authorized by the State of North Carolina, Department. of Environmental Quality
and the Coastal Resources C mission in an area o en i�onmental concern pursuant to 15A NCACy�
❑ R s attached.
Applicant Name " e- I P° 'i t J Project Location: County `— 1'1"
Address
City r I State ZIP
Phone # ( 3! 1 SL� J E-Mail
Authorized Agent
Affected ©CW El EW IJ PTA I ES ❑ PTS
: ❑OPA ElHHF L IH ❑ UBA L N/A
AEC(s
❑ PWS:
ORW: yes /(no I PNA yes / no
Type of Project/ Activity
Fixe
Float
Fing
Groff
Bulk
Basil
Boat
Boat
Beat
Othn
Sher
SAV
Street Address/ State Ro d/ Lot #(s)
Subdivision )
City e ZIP
Phone # O River Basin
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A building permit m e required by:
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name c'
Signature x. Please read compliance statement on back of permits'!
Ap I ation Fee(s)� Fees) C�ck#
❑ See note on back regarding River Basin rules.
PermitOmcer s Printed,Nam
Signaturet ;r
i�el �-1 • Ali
Issuing Pate I tid

Hurricane Florence and TS Michael
Replacement/Repair Request Form
Date of Request: V", — xw 9-
-
Property Owner Name:
Address of Property: a�'Ww / e0 A/,/
Telephone Number: q'& — 3e,2 � — 3V/ 9G2
Type of Work:
NOTE:
• The Emergency CAMA General Permit 2500 is for repairs and replacement of water -
dependent structures damaged because of Hurricane Florence and/or TS Michael. The
replacement, reconstruction and maintenance excavation activities shall conform to
current standards and rules. All work under the Emergency CAMA GP 2500 must be
made in the same footprint of the previous structure with no additions, expansions, or
enlargements.
• If any portion of a structure being replaced is within the 15' setback of the riparian line or
access area, signatures of the adjacent riparian property owner(s) must be obtained
acknowledging the notification and waiver of the setback on the forms provided by
DCM.
• Any maintenance excavation or dredging requires signatures of the adjacent riparian
property owner(s) on the notification forms provided by DCM.
Signature:
RECEIVED
JUN 2 8 2019
DCM-MHD CITY

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONANAIVER FORM
Name of Property Owner. G�lsa�/.?s : /yi'/%./ Address of Property: 23/ 7-:4 n 6 - �ii/as� ��Z
(Lot or Street #, Street or Road, City & County) /
Applicant phone#: %/O-_3Up_ /p941 Mailing Address: 7. 3/ o vs.2//,ry
.PraPa� �Sr<r/la, NC . Z 8.si3 z-
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the cleveloriment
they are proposing.
t/ 1 have no objections to this proposal. _I have objections to this proposal.
Nyou have objections to what Is being proposed, you mustnod& the Division of Coastal Management
(DCM) In writing within 10 days of receipt of this notice. Contact information /or DCM offices is
available at www.nccoestaimangementneNconfect dcm.htm or by calling 1.8"4RCOAST. No
response Is considered Me some as no objection ff you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to
waive the setback, you must initial the appropriate blank below.)
�T•F/�- I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Proper ty Owner I[Mormati",)
(Riparian Property Owner Information)
Sigimiure
Silievure
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Print or Type Name
Pnnt or Type Name
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Mailing Address
Mailing Address�7
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City/State2ip
CityiStat�e/Zip
�/'4 - CU60- 90y
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Telephone Number
Telephone Number
40 --025 — AIL2
6, z r-/�R
Date
Date
RECE
JUN 2 S 2019
DCM-MHD CITY

RECEIVED
JUN 2 S 2019
DCM-MHD CITY